After completing a 7‑day course of co‑amoxiclav 625 mg for a sore throat, I still have persistent sore throat and odynophagia; what should I do?

Persistent Sore Throat After Co-Amoxiclav: Next Steps

You need clinical re-assessment now to distinguish between treatment failure requiring a different antibiotic versus chronic streptococcal carriage with a concurrent viral infection.

Immediate Clinical Re-evaluation Required

Return for examination within 48–72 hours of persistent symptoms to confirm the original diagnosis and assess for complications 1. The majority of patients with true bacterial pharyngitis respond clinically to appropriate antimicrobial therapy, so ongoing symptoms warrant re-evaluation 1.

Key Diagnostic Considerations

You may be experiencing one of three scenarios:

• Treatment failure – the original bacterial infection has not been eradicated, requiring alternative antibiotic therapy 1
• Chronic GAS carrier with viral pharyngitis – you harbor Group A Streptococcus (GAS) chronically but your current symptoms are from a new viral infection 1
• Non-streptococcal pharyngitis – the original infection was not GAS, or you have developed a secondary infection 1

Management Algorithm for Symptomatic Patients After Co-Amoxiclav

If You Remain Symptomatic with Confirmed GAS

For symptomatic individuals who continue to harbor GAS after completing co-amoxiclav, reasonable options include 1:

• Clindamycin 20–30 mg/kg/day in 3 divided doses for 10 days (maximum 300 mg/dose) 1
• Intramuscular benzathine penicillin G (600,000 U if <27 kg; 1,200,000 U if ≥27 kg) as a single dose, especially if adherence to oral therapy is uncertain 1
• Narrow-spectrum cephalosporin such as cefdinir, cefuroxime, or cefpodoxime 1
• Penicillin V with rifampin (penicillin V 50 mg/kg/day in 4 doses × 10 days plus rifampin 20 mg/kg/day in 1 dose during the last 4 days; maximum rifampin 600 mg/day) 1

Clindamycin or benzathine penicillin G with rifampin are the most effective regimens for eradicating persistent GAS carriage 1.

Important Caveats About Chronic Carriers

Most patients with recurrent positive GAS tests are actually chronic carriers experiencing viral infections, not repeated bacterial infections 1. Chronic carriers:

• Have GAS present in the pharynx without an active immunologic response (no rising anti-streptococcal antibody titers) 1
• Are at very low risk for developing rheumatic fever or other complications 1
• Are unlikely to spread GAS to close contacts 1
• Do not ordinarily require antimicrobial therapy unless special circumstances exist 1

Helpful clues that you are a carrier with a viral infection rather than having true bacterial pharyngitis include 1:

• Prominent nasal symptoms (rhinorrhea, congestion)
• Cough
• Hoarseness
• Conjunctivitis
• Diarrhea
• Absence of fever or exudate

When Carrier Treatment IS Indicated

Eradication of chronic GAS carriage is only recommended in special situations 1:

• During a community outbreak of acute rheumatic fever or invasive GAS infection
• Personal or family history of acute rheumatic fever
• Outbreak of GAS pharyngitis in a closed community
• Excessive family anxiety about GAS infections
• When tonsillectomy is being considered solely because of carriage

What NOT to Do

Do not use the following antibiotics for persistent pharyngitis 1:

• Tetracyclines – high prevalence of resistant GAS strains 1
• Trimethoprim-sulfamethoxazole – does not eradicate GAS 1
• Older fluoroquinolones (ciprofloxacin) – limited activity against GAS 1
• Newer fluoroquinolones (levofloxacin, moxifloxacin) – unnecessarily broad spectrum and expensive 1

Repeated courses of antibiotics are rarely indicated in asymptomatic patients who continue to harbor GAS 1.

Symptomatic Relief

While awaiting re-evaluation, continue symptomatic management:

• Analgesics (acetaminophen or ibuprofen) for pain relief 1
• Warm salt water gargles may provide temporary relief, though not formally studied 1
• Topical anesthetics (lozenges, sprays with benzocaine or lidocaine) may give temporary symptomatic relief 1

Critical Next Step

Schedule clinical re-assessment immediately – do not simply request another course of antibiotics without examination 1. Your clinician needs to:

• Confirm the diagnosis with throat examination
• Consider repeat throat culture or rapid antigen detection test
• Rule out complications (peritonsillar abscess, retropharyngeal abscess)
• Assess for non-GAS causes (Epstein-Barr virus, group C or G streptococci)
• Determine whether you are a chronic carrier versus having treatment failure

A single additional course of appropriate antibiotic therapy should be administered if you have acute pharyngitis symptoms with evidence of GAS, even if you may be a carrier 1. However, the specific choice of antibiotic should be guided by your clinical presentation and the considerations outlined above.